User:Sticky Parkin/APD

Antisocial personality disorder (APD) is a psychiatric condition characterized by an individual's common disregard for social rules, norms, and cultural codes, as well as impulsive behavior, and indifference to the rights and feelings of others. Antisocial personality disorder is terminology used by the American Psychiatric Association's Diagnostic and Statistical Manual, while the World Health Organization's ICD-10 refers to Dissocial personality disorder.

The official stance of the American Psychiatric Association as presented in the DSM-IV-TR is that psychopathy and sociopathy are obsolete synonyms for antisocial personality disorder (APD). The World Health Organization takes a similar stance in its ICD-10 by referring to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for dissocial personality disorder.

Psychologist Robert Hare and those who work with his theories, are working toward listing psychopathy as a unique disorder. However he has not succeeded and the term has been dropped in favor of Antisocial Personality Disorder. Followers of Hare will still use the term 'psychopath' in their work, when it is not used in a formal context by other medical professionals.

Antisocial personality disorder is often misunderstood by laypeople. The term antisocial is often, incorrectly, confused with unsociable or shy.

History
Research into a group of individuals that could be described as psychopathic was first completed by Philippe Pinel almost 200 years ago. Pinel described patients as "insane without delirium," which he characterized as a lack of restraint and remorselessness for their actions. Pinel felt that his patients were morally neutral, reflecting his humanistic approach to mental illness. The 19th century term used for such individuals was "moral imbecile"

The next most distinctive work on psychopaths was done in 1941 by Hervey Cleckley in his book The Mask of Sanity (significantly expanded in the second edition of 1950). Cleckley offered a broad range of case histories, from all corners of society, all of which showed patients with the common characteristic of "emotional emptiness." Cleckley probed the psychopath's attitudes and thought patterns in search of a meaning for their unusual behaviour; however, according to Robert Hare, Cleckley's most important contribution was in providing the framework of emotion for most future research into this disorder.

According to Cleckley, such individuals were diagnosed in the psychiatric nomenclature of the United States as a psychopathic personality until 1952 when the term was replaced by sociopathic personality. In 1968, the official terminology was changed to personality disorder, antisocial type. In 1980 the DSM-III changed the term slightly to antisocial personality disorder, a personality disorder being a term that officially includes a variety of maladjusted persons who are not psychotic or mentally impaired.

Diagnostic criteria
The manual lists the following additional necessary criteria:
 * 1) Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
 * 2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
 * 3) Impulsivity or failure to plan ahead
 * 4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults
 * 5) Reckless disregard for safety of self or others
 * 6) Consistent irresponsibility, as indicated by repeated failure to sustain steady work or honor financial obligations
 * 7) Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
 * 8) Insensitivity to pain
 * The individual is at least 18 years of age.
 * There is evidence of conduct disorder with onset before age 15 years.
 * The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

Causes
The cause of this disorder is unknown, but biological or genetic factors may play a role. However, the statistical correlation between the disorder and biological factors is weak, leading many experts to believe otherwise.

A family history of the disorder — such as having an antisocial parent — increases the chances of developing the condition. A number of environmental factors within the childhood home, school and community, such as an overly punitive home or school environment may also contribute.

Robins (1966) found an increased incidence of sociopathic characteristics and alcoholism in the fathers of individuals with antisocial personality disorder. He found that, within such a family, males had an increased incidence of APD, whereas females tended to show an increased incidence of somatization disorder instead.

Bowlby (1944) saw a connection between antisocial personality disorder and maternal deprivation in the first five years of life. Glueck and Glueck (1968) saw indications that the mothers of children who developed this personality disorder tended to display a lack of consistent discipline and affection, and an abnormal tendency to alcoholism and impulsiveness. These factors all contribute to a failure to create a stable and functional home with consistent structure and behavioral boundaries.

Adoption studies support the role of both genetic and environmental contributions to the development of the disorder. Twin studies also indicate an element of hereditability of antisocial behaviour in adults and have shown that genetic factors are more important in adults than in antisocial children or adolescents where shared environmental factors are more important. (Lyons et al., 1995)

Symptoms
Common characteristics of people with antisocial personality disorder include:
 * Persistent lying or stealing
 * Recurring difficulties with the law
 * Tendency to violate the rights and boundaries of others (property, physical, sexual, emotional, legal)
 * Substance abuse
 * Aggressive, often violent behavior; prone to getting involved in fights
 * A persistent agitated or depressed feeling (dysphoria)
 * Inability to tolerate boredom
 * Disregard for the safety of self or others
 * A childhood diagnosis of conduct disorders
 * Lack of remorse for hurting others
 * Superficial charm
 * Impulsiveness
 * A sense of extreme entitlement
 * Inability to make or keep friends
 * Lack of guilt
 * Relentlessness
 * being completely insensitive to pain
 * Recklessness, impulsivity

People who have antisocial personality disorder often experience difficulties with authority figures.

Prevalence
The National Comorbidity Survey, which used DSM-III-R criteria, found that 5.8 percent of males and 1.2 percent of females showed evidence of a lifetime risk for the disorder. In penitentiaries, the percentage is estimated to be as high as 75 percent. Prevalence estimates within clinical settings have varied from three to 30 percent, depending on the predominant characteristics of the populations being sampled. {Diagnostic and Statistical Manual of Mental Disorders} Perhaps not surprisingly, the prevalence of the disorder is even higher in selected populations, such as people in prisons (who include many violent offenders) (Hare 1983). Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) abuse treatment programs than in the general population (Hare 1983), suggesting a link between ASPD and AOD abuse and dependence.

Relationship with other mental disorders
Antisocial personality disorder is negatively correlated with all DSM-IV Axis I disorders except substance abuse disorders. Antisocial personality disorder is most strongly correlated with psychopathy as measured on the Psychopathy Checklist-Revised (PCL-R).

Potential markers
Although antisocial personality disorder cannot be formally diagnosed before age 18, three markers for the disorder, known as the MacDonald Triad, can be found in some children. These are, a longer-than-usual period of bedwetting, cruelty to animals, and pyromania.

It is not known how many children who exhibit these signs grow up to develop antisocial personality disorder, but these signs are often found in the histories of diagnosed adults. Because it is unknown how many children have these symptoms and who do not develop antisocial personality disorder, the predictive value (ie, the usefulness of these symptoms for predicting future antisocial personality disorder) is unclear.

These three traits are now included in the Diagnostic and Statistical Manual of Mental Disorders IV-TR under conduct disorder.

A child who shows signs of antisocial personality disorder may be diagnosed as having either conduct disorder or oppositional defiant disorder. Not all of these children, however, will grow up to develop antisocial personality disorder.

Psychopathy is not normally diagnosed in children or adolescents, and some jurisdictions explicitly forbid diagnosing psychopathy and similar personality disorders in minors. Psychopathic tendencies can sometimes be recognized in childhood or early adolescence and, if recognised, are diagnosed as conduct disorder. It must be stressed that not all children diagnosed with conduct disorder grow up to be psychopaths, or even disordered at all, but these childhood signs are found in significantly higher proportions in psychopaths than in the general population. Conduct disorder, as well as its subcategory Oppositional Defiance Disorder, can sometimes develop into adult psychopathy. However, conduct disorder "fails to capture the emotional, cognitive and interpersonality traits - egocentricity, lack of remorse, empathy or guilt - that are so important in the diagnosis of psychopathy."

Children showing strong psychopathic precursors often appear immune to punishment; nothing seems to modify their undesirable behavior. Consequently parents usually give up, and the behavior worsens.

The following childhood indicators are to be interpreted not as to the type of behavior, but as to its relentless and unvarying occurrence. Not all must be present concurrently, but at least a number of them need to be present over a period of years:
 * An extended period of bedwetting past the preschool years that is not due to any medical problem.
 * Cruelty to animals beyond an angry outburst.
 * Firesetting and other vandalism. Not to be confused with playing with matches, which is not uncommon for preschoolers. This is the deliberate setting of destructive fires with utter disregard for the property and lives of others.
 * Lying, often without discernible objectives, extending beyond a child's normal impulse not to be punished. Lies that are so extensive that it is often impossible to know lies from truth.
 * Theft and truancy.
 * Aggression to peers, not necessarily physical, which can include getting others into trouble or a campaign of psychological torment.

The three indicators&mdash;bedwetting, cruelty to animals and firestarting, known as the MacDonald triad&mdash;were first described by J.M. MacDonald as indicators of psychopathy. Though the relevance of these indicators to serial murder etiology has since been called into question, they are considered relevant to psychopathy.

The question of whether young children with early indicators of psychopathy respond poorly to intervention compared to conduct disordered children without these traits has only recently been examined in controlled clinical research. The findings from this research are consistent with broader evidence - pointing to poor treatment outcomes.

Criticism of the DSM-IV criteria
The DSM-IV confound: some argue that an important distinction has been lost by including both sociopathy and psychopathy together under APD. As Hare et al write in their abstract, "The Axis II Work Group of the Task Force on DSM-IV has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions", concluding, "... conceptual and empirical arguments exist for evaluating alternative approaches to the assessment of psychopathy ... our hope is that the information presented here will stimulate further research on the comparative validity of diagnostic criteria for psychopathy; although too late to influence DSM-IV."

Hare and others take the stance that psychopathy as a syndrome should be considered distinct from the DSM-IV's antisocial personality disorder construct, even though APD and psychopathy were intended to be equivalent in the DSM-IV. However, those who created the DSM-IV felt that there was too much room for subjectivity on the part of clinicians when identifying things like remorse and guilt; therefore, the DSM-IV panel decided to stick to observable behaviour, namely socially deviant behaviours. As a result, the diagnosis of APD is something that the "majority of criminals easily meet." Hare goes further to say that the percentage of incarcerated criminals that meet the requirements of APD is somewhere between 80 to 85 percent, whereas only about 20% of these criminals would qualify for a diagnosis of psychopath. This twenty percent, according to Hare, accounts for 50 percent of all the most serious crimes committed, including half of all serial and repeat rapists. According to FBI reports, 44 percent of all police officer murders in 1992 were committed by psychopaths. Followers of Hare use the to differentiation between individuals who they define as psychopaths and those with antisocial personality disorder]] (APD).

Sex differences: APD is diagnosed much more frequently in men than in women. The DSM-IV diagnostic criteria does not take into account relational aggression, in which women are more likely to engage than physical aggression.

Treatments
It has been shown that punishment and behavior modification techniques do not improve the behavior of a psychopath. They have been regularly observed to respond to both by becoming more cunning and hiding their behavior better. It has been suggested that traditional therapeutic approaches actually make them, if not worse, then far more adept at manipulating others and concealing their behavior. They are generally considered to be not only incurable but also untreatable.

Legal definition
Psychopathy has quite separate legal and judicial definitions that should not be confused with the medical definition. Various states and nations have at various times enacted laws specific to dealing with psychopathic offenders, and many of these laws are active, on statute, today:
 * Washington State Legislature defines a "Psychopathic personality" to mean "the existence in any person of such hereditary, congenital or acquired condition affecting the emotional or volitional rather than the intellectual field and manifested by anomalies of such character as to render satisfactory social adjustment of such person difficult or impossible". However, courts and legistatures do not diagnose so the legal purpose of this definition is unclear.
 * California enacted a psychopathic offender law in 1939 that defined a psychopath solely in terms of offenders with a predisposition "to the commission of sexual offenses against children." A 1941 law attempted to further clarify this to the point where anyone examined and found to be psychopathic was to be committed to a state hospital and anyone else was to be sentenced by the courts. However, these laws were enacted years before the American Psychiatric Association began publishing the Diagnostic and Statistical Manual of Mental Disorders which is used today for diagnosis and does not include "psychopathic offender". Hence, these laws are of historical interest only.
 * In the United Kingdom, "Psychopathic Disorder" is legally defined in the Mental Health Act (UK) as, "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned."

PCL-R Factors
The following findings are for research purposes only, and are not used in clinical diagnosis.

Early factor analysis of the PCL-R indicated that it consisted of two factors. Factor 1 capture traits dealing with the interpersonal and affective deficits of psychopathy (e.g. shallow affect, superficial charm, manipulativeness, lack of empathy) whereas Factor 2 dealt with symptoms relating to anti-social behaviour (e.g. criminal versatility, impulsiveness, irresponsibility, poor behaviour controls, juvenile delinquency). The two factors have been found to display different correlates. Factor 1 has been correlated with narcissitic personality disorder, low anxiety , low empathy , low stress reaction and low suicide risk but high scores on scales of achievement and well-being. In contrast, Factor 2 was found to be related to anti-social personality disorder, social deviance , sensation seeking , low socio-economic status and high risk of suicide. The two factors are nonetheless highly correlated and there are strong indications that they do result from a single underlying disorder. However, research has failed to replicate the two-factor model in female samples.

Recent statistical analysis using confirmatory factor analysis by Cooke and Michie indicated a three-factor structure, with those items from factor 2 strictly relating to anti-social behaviour (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioural problems and poor behavioural controls) removed from the final model. The remain items divided into three factors: Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience and Impulsive and Irresponsible Behavioural Style. In the most recent edition of the PCL-R, Hare adds a fourth Antisocial behaviour factor, consisting of those Factor 2 items excluded in the previous model. Again, these models are presumed to be hierarchical with a single unified psychopathy disorder underlying the distinct but correlated factors.

The Primary - Secondary distinction
Primary psychopathy was defined as the root disorder in patients diagnosed with it whereas secondary psychopathy was defined as an aspect of another psychiatric disorder or social circumstances. Today, primary psychopaths are considered to have mostly Factor 1 traits from the PCL-R (arrogance, callousness, manipulativeness, lying) whereas secondary psychopaths have a majority of Factor 2 traits (impulsivity, boredom proneness, irresponsibility, lack of long-term goals). Secondary psychopaths show normal to above-normal physiological responses to (perceived) potential threats. Their crimes tend to be unplanned and impulsive with little thought of the consequences. They have hot tempers and are prone to reactive aggression. They experience normal to above-normal levels of anxiety but are nevertheless highly stimulus seeking and have trouble tolerating boredom. Their lifestyle may lead to depression and even suicide.

Mealey uses the term "primary psychopathy" to differentiate between psychopathy that is biological in origin and "secondary psychopathy" that results from a combination of genetic and environmental influences. Lykken prefers sociopathy to describe the latter.

Sellbom and Ben-Porath (2005) describe the distinction succinctly:


 * Some people who engage in violent behavior possess psychopathic personality traits, such as callousness, grandiosity, and fearlessness, and presumably engage in such conduct because they care little about others. Others are impulsive and experience considerable anger, anxiety, and distress and may commit violent acts as a reaction to negative emotions, which are sometimes referred to as "crimes of passion." Indeed, the distinction between primary and secondary psychopathy (including so-called neurotic psychopathy) has long been noted in the psychopathy literature (Karpman, 1947; Lykken, 1995).

This distinction closely resembles the distinction between instrumental and impulsive/reactive crime/violence in the field of criminology.

Joseph P. Newman et al. have validated David T. Lykken's conceptualization of psychopathy subtypes in relation to Gray's behavioral activation system and behavioral inhibition system. Newman et al. found measures of primary psychopathy to be negatively correlated with Gray's behavioral inhibition system, a construct intended to measure behavioral inhibition from cues of punishment or nonreward. In contrast, measures of secondary psychopathy to be positively correlated with Gray's behavioral activation system, a construct intended to measure sensitivity to cues of behavioral approach.

Relationship with other mental disorders
Psychopathy, as measured on the PCL-R, is negatively correlated with all DSM-IV Axis I disorders except substance abuse disorders. Psychopathy is most strongly correlated with DSM-IV antisocial personality disorder. PCL-R Factor 1 is correlated with narcissistic personality disorder and histrionic personality disorder. PCL-R Factor 2 is particularly strongly correlated to antisocial personality disorder and criminality.

PCL-R Factor 2 is associated with reactive anger, anxiety, increased risk of suicide, criminality, and impulsive violence. PCL-R Factor 1, in contrast, is associated with extroversion and positive affect.

Sociopathy
The difference between sociopathy and psychopathy, according to Hare, may "reflect the user's views on the origins and determinates of the disorder."

David T. Lykken proposes that psychopathy and sociopathy are two distinct kinds of antisocial personality. He holds that psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, and fearlessness that lead them to risk-seeking behavior and an inability to internalize social norms; sociopaths, on the other hand, have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. Both personality disorders are, of course, the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.

Pseudopsychopathic personality disorder
It has been suggested that people can suffer apparently psychopathic personality changes from lesions or damage of the brain's frontal lobe. This is sometimes called pseudopsychopathic personality disorder or frontal lobe disorder.

Discrete taxon vs. continuous dimension
As part of the larger debate on whether personality disorders are distinct from normal personality or extremes on various dimensions of normal personality is the debate on whether psychopathy represents something "qualitatively different" from normal personality or a "continuous dimension" shading from normality into severely psychopathic. Early taxonometric analysis from Harris and colleagues indicated that a discrete category may underlie psychopathy, however this was only found for the behavioural Factor 2 items, indicating that this analysis may be related to Anti-social Personality Disorder rather than psychopathy per se. John Marcus, and Edens more recently performed a series of statistical analysis on previously attained PCL–R and PPI scores and concluded that psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.

In contrast, the PCL–R sets a score of 30 out of 40 for North American male inmates as its cut-off point for a diagnosis of psychopathy, however this is an abitrary cut-off and should not be taken to reflect any sort of underlying structure for the disorder.

Perceptual/emotional recognition deficits
In a 2002 study, David Kosson and Yana Suchy, et al. asked psychopathic inmates to name the emotion expressed on each of 30 faces; compared to controls, psychopaths had a significantly lower rate of accuracy in recognizing disgusted facial affect but a higher rate of accuracy in recognizing anger. Additionally, when "conditions designed to minimize the involvement of left-hemispheric mechanisms" were used, psychopaths had more difficulty accurately identifying emotions. This study did not replicate Blaire, et al. (1997)'s findings that psychopaths are specifically less sensitive to nonverbal cues of fear or distress.

In a 2002 experiment, Mitchell Blair et al. used the Vocal Affect Recognition Test to measure psychopaths' recognition of the emotional intonation given to connotatively neutral words. Psychopaths tended to make more recognition errors than controls with a particularly high rate of error for sad and fearful vocal affect.

A 2004 experiment tested the hypothesis of overselective attention in psychopaths using two forms of the Stroop color-word and picture-word tasks: with color/picture and word separated and with color/picture and word together. They found that in the separated Stroop tasks, psychopaths performed significantly worse than controls; however, on standard Stroop tasks, psychopaths performed equally well as controls.

When split into low-anxious and high-anxious groups, low-anxious psychopaths and low-anxious controls showed less interference on the separated Stroop tasks than their high-anxious counterparts; for low-anxious psychopaths, interference was very nearly zero. They conclude that the inability to integrate contextual cues depends on the cues' relationship to "the deliberately attended, goal-relevant information."